There are a few “laws” of the blogosphere, one of them being that a response to a post that comes more than a few weeks later is generally useless or crazy.  But once in a while, someone takes the time to look at an old post and formulate a thoughtful response.

This is not one of those times.

Or maybe it is.  I’ll report (and editorialize), you decide.

Regarding a piece I first published in September of 2010, a reader writes:

Dear Dr. Gorski:[our managing editor]

I am writing regarding your comments on the following blog

Your disease, your fault

I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written. I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease. I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education. I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.

In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.

I await your response.

Sincerely,

[Name redacted]

What is instructive here is the usual thoughtful but incorrect “reasoning” used by someone with just enough knowledge to think he understands the topic at hand well enough to rebut.  The rebuttal, however, makes use of the usual fallacies that are the fallback position for the ignorant and the mendacious (and I must point out that I think our Dear Correspondent is the former).

Since I wrote the piece, not Dr. Gorski, I take full responsibility for its content and defend my writing personally.  A bit of a fisking is in order to help us all better understand how to think about these questions properly.

I am not a doctor but am pursuing an MA and hopefully a PhD in nutrition and public health. I am very familiar with Dr. Fuhrman and his work. I have heard many of Dr. Fuhrman’s lectures and if anything they are all based on concrete scientific research. I must express my disappointment about both the tone and factual content of the article written.

The writer first tries to establish himself as an authority on nutrition, public health, and one Dr. Fuhrman (the putative antagonist of my piece) as a reliable source of that authority.  Even if we were to be convinced by his level of authority, it is irrelevant to his arguments.   Our Dear Correspondent could be a Nobel laureate in physics, but this is no guarantee of relevant expertise.

Then he begs the question: he asserts that Dr. Fuhrman’s works are “all based on concrete scientific research”.  This may or may not be true, but it does not refute the points made in my post, such as Furhman’s stated idea that all disease is preventable with just the right lifestyle and avoidance of medication.

He finishes his point with a non sequitur (although one that loyal reader Peter Moran might agree with), that somehow my tone renders my argument less valid.  If I were to point at the sky and shout, “It’s &%$# blue, you ass!” the statement would be no less true for its crudeness.

I read extensively about nutrition, exercise and their health benefits. Much of the research done in this field has been conducted in small clinical trials or in the laboratory. There is a good reason for this. Only the government has the financial ability to pay the tens of millions of dollars needed to conduct large scale clinical trials in this area since a drug company would in all probability not have any financial gain from a clinical trial showing that individuals eating 10 servings of vegetables each day have a significant reduction in chronic disease.

This is simply untrue.  There is an enormous body of research on nutrition and exercise physiology.  Just glancing at today’s issue of the American Journal of Cardiology, we see Impact of Body Mass Index, Physical Activity, and Other Clinical Factors on Cardiorespiratory Fitness (from the Cooper Center Longitudinal Study); from The Lancet, a summary of Salt and cardiovascular disease mortality. These fields (nutrition, exercise) are and have been active areas of high quality research, just not to the exclusion of all else.  It would be rather foolish to focus on only one set of tools to prevent a heart attack.  When lifestyle modification is inadequate, it is not a failure of the patient, the doctor, or science-based medicine, but a simple case of “stuff happens” and it’s time to crack open another tool box.

These facts render irrelevant his subsequent suspicion-filled assumptions about the economics of medicine.  The government funds a great deal of this research, but so do pharmaceutical and related industries.  There is always a profit to be made, whether by developing a new drug, or opening a Whole Foods with aisles full of magic (some of which is quite healthy and quite tasty).

I do feel that all epidemiological as well as clinical work done points to the very clear fact that people die years before they need to due to the poor diets they have. It is also very clear that most physicians have very little knowledge about nutrition since it is generally a very minor part of their education.

Not to wax Crislipian, but Duh! Our country is suffering from an epidemic of obesity, leading to early, preventable deaths.  That’s not particularly controversial.  It’s also not a mystery that many physicians receive an inadequate education in nutrition.  The fallacy here is that it is better to worship a false god than to seek true knowledge.  The cure to our ignorance is not to listen to some pseudo-expert who is completely wrong about disease prevention and treatment, but to improve our education of the public and our professionals.

I agree with doctor Fuhrman that any debate should be both science based and held to the highest ethical standards. From what I see the article written as well as your comments do not meet these standards. I find that most disconcerting due to the fact that individuals put their lives in their hands when they consult with you as a physician.

Well, that’s just ad hominem nonsense.  What counts is facts, not one writer’s opinion about tone and ethics.  This statement betrays a complete misunderstanding of medical ethics.  Our duty, as physicians, is first to our patients, then to the wider public.  We must treat the patient in front of us with the best science-based medicine has to offer, delivered with compassion.  We must educate the public to teach the difference between real doctors and carnival barkers (h/t POTUS).

In closing I would like your comment on the follwing statement that was made by Dr. William Castelli, who ran the Framingham Study for about 20 years. An interviewer asked him what percent of heart disease could be avoided through proper nutrition and exercise. His response was very brief. 100%!! Do you agree with one of foremost reaearcers of the 20th century or do you consider him to be a quack too.

I’m not so sure about that Castelli quote.  He has a history of some pretty bold pronouncements that don’t quite follow the evidence, but if you dig into his efforts a bit deeper, you can see that he clearly doesn’t believe the statement above:

Castelli concedes diet and exercise won’t help the 5 to 10 percent of people who’s heart disease is genetic. The genetic predisposition to heart disease is responsible for 85% of heart attacks suffered by people under 65. These people often have cholesterol levels of a whopping 300 or higher. Medication can save their lives, but the health care system, Castelli charges, doesn’t do a good enough job of finding these patients in time.

If our Dear Correspondent would like to learn more about how to think more clearly about medicine and science, this blog has been live for a few years now and offers a treasure trove for those interested in banishing ignorance, or at least learning to tell fact from its opposite.

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